The prevalence of autism or autism spectrum disorder (ASD) is increasing. In fact, it is now being called the “autism epidemic”. Almost 1 in 31 children in the USA is affected by autism.
Applied Behavior Analysis (ABA) therapy is commonly used to manage this condition. According to the latest research, ABA therapy has a remarkable success rate of more than 89% in improving social skills and adaptive behaviors in children with ASD. However, the technicians and certified therapists struggle with the challenges of medical billing. They often have to divert their attention from the therapy to its billing. So, we have decided to make this path easier for them.
This blog discusses the basic information you need to bill CPT code 97153. It covers the code’s description, use in clinical practice, and some essential billing tips. So let’s start this journey without further delay!
What is CPT Code 97153?
CPT code 97153 is a medical procedural code that falls under the ‘Adaptive Behavior Treatment Procedures’ code range.
It represents adaptive behavior treatment services delivered by a technician under the supervision of a physician or other certified healthcare professional. The technician-patient encounter must be face-to-face and last at least 15 minutes.
In simple words, a technician provides adaptive behavior treatments targeting conditions such as developmental disabilities associated with adaptive or maladaptive behaviors, impaired social skills, and communication in accordance with an established protocol.
Scenarios Where CPT Code 97153 is Applicable
Does this description still sound confusing? Read the following examples to understand the application of CPT code 97153:
Autism Spectrum Disorder (ASD)
Consider the example of a 7-year-old child with Autism Spectrum Disorder (ASD). He exhibits multiple developmental and behavioral symptoms. The technician implements a treatment plan pre-designed by a board-certified behavior analyst (BCBA). He spends 30 minutes of face-to-face time with the child, adhering to the training procedures mentioned in the plan.
Since the technician provided one-on-one services for an adaptive behavior treatment procedure under professional supervision, he can use two units of CPT code 97153.
Self-Injurious Behavior (SIB)
Take another example of self-injurious behavior SIB, because almost 50% of children and adults with ASD engage in SIB. So think of an 8-year-old child with autism who is showing multiple SIB in his routine, like hand biting and skin peeling. The technician follows the pre-designed treatment plan to manage this harmful behavior. He spends 60 minutes providing behavioral training to the child.
Since the technician provided one-on-one services for an adaptive behavior treatment procedure under the supervision of a BCBA, he must bill four units of CPT code 97153.
Activities of Daily Living
Assume a 10-year-old child has difficulty performing personal tasks independently, such as brushing her teeth and washing her hands. To address these shortcomings, the youngster is engaged in an Applied Behavior Analysis (ABA) therapy program. A registered behavior technician (RBT) conducts a one-on-one session with the child as part of her methodical treatment plan under the supervision of a certified behavior analyst.
The service can be billed with CPT code 97153, since the session entails the direct, in-person application of adaptive behavior treatment per protocol, provided by a technician.
Applicable Modifiers for CPT Code 97153
The following are some modifiers that you may use with CPT code 97153. However, every insurance payer may have their own modifier requirements.
Modifier 95/GT
You may apply modifier 95 or GT with CPT code 97153 if the technician provided the therapy session using a synchronous real-time audio and video telecommunication system.
Note: Modifier 95 and GT both serve the same purpose. However, some payers accept modifier 95, whereas some accept claims with modifier GT for telehealth services.
Modifier HN
Modifier HN is used with CPT code 97153 to indicate that the adaptive behavior treatment is administered by an assistant-level therapist, such as a Bachelor’s level provider.
Modifier HM
Modifier HM is used with CPT code 97153 to indicate that the adaptive behavior treatment is administered by a therapist who holds less than a bachelor’s degree.
CPT Code 97153 – Billing & Reimbursement Guidelines
Now is the time for some important billing and reimbursement guidelines related to CPT code 97153.
Include Detailed Documentation
This ABA therapy code requires proper documentation of the whole procedure for accurate billing. The technician must record and/or retrieve the patient’s medical history while performing the procedure. Furthermore, here’s a list of some essential details that your documentation must include:
- Specific behavioral goals which were targeted during the therapy.
- Precise recording of the start and stop times of the session with the patient to calculate billable units per the 8-minute rule.
- Proof that the session adhered to the treatment plan approved by the BCBA.
- Proof of physician supervision.
- A justification of the billed units mentioning the total session time.
- The place of service.
- Complete session notes with the technician’s signature.
Ensure Time Tracking
The most crucial element in CPT code 97153 billing is time. Only in-person interactions between the therapist and the patient are eligible for this code, and only the time spent actively carrying out treatment plans is eligible for billing. You must keep track of the start and end timings to determine the billable units in accordance with the 8-minute guideline.
Follow the Payers’ Guidelines
Verifying and adhering to the insurance payers’ policies is the final, but no less important, step to remember. For example, each payer accepts modifiers according to their own rules. Similarly, they have their own specifications for service documentation. Therefore, you must make sure that your claim and supporting documentation comply with the targeted payer’s billing requirements.
Final Word
It is time to take our leave. But before that, let’s review what we discovered on the billing of CPT code 97153. We discussed the basic description of the code and its practical uses, essentially for the treatment of maladaptive behaviors in autistic children. Then, we shared some modifiers that may be appended to the code, depending on the payer’s policies. Finally, we discussed vital details that must be included in the supporting paperwork, and that billing units must be calculated using the Medicare 8-minute rule.
Hopefully, now you will be able to file claims for your ABA therapies with ease. However, if you still struggle, consider collaborating with an expert ABA therapy billing services provider. It will streamline your billing, helping you focus on improving your patients’ lives.
